Why Bone Health is SO Important as we Age

When it comes to bones, we tend to take our bones for granted. We can’t see them…..or feel them, yet they are the main mechanical scaffolding we have to keep our body structured and upright. Bones are also needed to attach muscle to, via incredibly strong and resilient tendons. Like tendons, ligaments too are also needed to keep bones in place, again to maintain overall structural integrity.

Bones are actually living tissue that includes the combination of not only bone itself, but also nerves, cartilage and connective tissues (tendons & ligaments), with blood vessels supplying important nutrients to the bones.

The bone itself is composed of two types of bone as you can see in the illustration. On the outside we have the hard, ‘cortical’ bone and on the inside we have a honeycomb like structure called ‘trabecular’ bone.

Only around 65% of bone is actually composed of hard mineral substances, with the rest being organic (mostly protein) providing extra strength, durability and flexibility. Collagen is the main protein in bone which literally holds the calcium structure together, rather likes bricks and mortar.

It’s All Downhill after 30!

In younger adults, loss of bone and formation of new bone is equal and this is a dynamic and ongoing re-modelling process throughout our whole life.

Basically there are two types of cell that affect bone health….firstly we have the osteoblasts, which are bone building cells and then we have the osteoclasts, which are the bone dismantling cells. It is this equilibrium process which keeps our bones in good health…..but as we age, the process of bone resorption ie loss, is more significant, resulting in a loss of bone density and bone strength over time.

By the time we reach 30 years old, our bones have reached peak bone strength and mass, with after 35yrs old being the start of bone mass decline. This is significantly accelerated during the female menopause, though men do not escape this bone loss totally with age.

 During the menopause, this bone loss accelerates dramatically and some will unfortunately go on to osteoporosis, which then needs to be managed carefully in consultation with your GP.

According to the National Osteoporosis Society (NOS), around 50% of women will exhibit osteoporosis during their lives, but this will also affect around 20% of men too, though many do not even realise that their bone mass and bone strength has declined until they end up with a fracture.

Those with osteoporosis are much more prone to fractures, caused not by a serious fall or trauma, but perhaps due to a much ‘gentler’ knock or even just a strain such as even just getting out of chair. This is referred to as a ‘fragility fracture’ and is classical osteoporosis. The most common place for such a fracture is in our wrists, hips and our spine.

There is a significant hereditary factor for osteoporosis too, so if your mother for example has had a hip fracture, it is possible that you may be more prone to the disease, so it’s worth talking to your doctor and getting this checked out using the DEXA scanning technique, as described below.

So how can you tell if you have Osteoporosis? 

Many women undergo what is called DEXA (dual energy x-ray absorptiometry), which is a quick and simple procedure using low dose x rays, to examine the bone density of the hip and spine and is a very useful tool to determine if you have osteoporosis or simply have osteopenia, which is weaker bone mass than normal, though not quite enough to be diagnosed with osteoporosis itself.

This can calculate how dense your bones are and it compares this against what is regarded as a normal bone density. A ‘T score’ is usually given and this is a way of making this comparison arithmetically rather than just pictorially. This score is then taken together with other risk factors to work out how likely you are to get a fracture in the future and whether you will need any medication or not.

A score of -1 or higher is considered normal. A lower score between -1.1 and -2.4 is classified as osteopenia (low bone mass, that is not quite osteoporosis). A person with a T score of -2.5 or lower has even less bone mass/strength and meet the criteria for a diagnosis of osteoporosis.

The FRAX score is another way of estimating your risk of fracture in the future and this does not even require a DEXA scan to make the assessment. FRAX is based on an algorithm taking into account your health history , your diet, whether you smoke/drink and other factors. Also, whether there is osteoporosis in the family. This risk assessment in combination with your DEXA score can give you a really good idea as to your risk of osteoporosis in the future.

Exercise is an excellent aid to building bone strength amongst it’s many other health benefits. The best form of exercise is weight bearing such as jogging, aerobics, zumba and weight training. Swimming and cycling are clearly good forms of exercise, but this will do little for bone building in comparison.

Medication? 

It’s not just ageing that can affect bone health, but also some medical conditions and even some medicines can speed up bone loss. Oral steroids are known to affect bone density.  Estrogen lowering drugs too can affect bone strength. Smoking and drinking is unhealthy for bone health, as is being either underweight and overweight.

For those with diagnosed osteoporosis, there is a selection of drugs that can be tailored to your requirements, so this is a discussion you need to have with your own doctor of course. The front line drugs include a family of drugs called ‘bisphosphonates’ such as alendronic acid and these can be taken as a tablet or an injection and can be administered daily (eg tabs), weekly or even monthly. These are quite powerful drugs with some side- affects and your doctor will be able to give you a personalised approach, based on a range of other factors such as what other meds you are on, your diet, your lifestyle and so on.

These drugs do require certain conditions such as an empty stomach and taken with a large glass of water, whilst remaining upright for a good hour or two. Others include SERMS (selective oestrogen receptor modulators) which are drugs which help maintain bone density and work to protect bone in a similar manner to protective oestrogen itself.

Do I need Supplements?

We know from regular ‘Diet & Nutrition Studies’, where food intake is measured across thousands of people across the UK, that the vast majority of older adults are simply not getting the RDA (the recommended daily target) of Vitamin D, Calcium, Magnesium and many more relevant micronutrients, all of which are required for optimal bone health. 

Calcium

Calcium is the most abundant mineral found in the body and typically daily needs are around 800mg. Your body actually contains around a kilogram of calcium and 99% of this calcium is found in your skeleton, helping to give the bones their strength, together with other minerals such as phosphorus , in a combined structure called hydroxy-apatite.

Dietary calcium is needed to ensure that healthy bone is built and the amount of calcium you need daily is around 800mg (the RDA) and this is especially important as we age, or bone strength may reduce faster than normal. Unfortunately, data from UK food intake studies across thousands of people show clearly that nearly half of older adults fail to get even that minimum daily target and so are putting themselves into an unhealthy situation re their bone health.

Also, calcium absorption can be reduced in the ageing gut. Furthermore, bones lose their density and strength with age, especially in post-menopausal women and it is therefore essential to ensure that we are getting enough calcium. Failure to do this can lead to accelerated bone density loss and increased risk of fractures too.

Of course, even if calcium is in plentiful supply, efficient calcium absorption is also needed and this is very much dependent on getting enough vitamin D too.

Finally, one note of caution….as with all nutrients, too much of a good thing can become toxic at high levels and calcium is no exception. High intakes of calcium have been associated with increased arterial plaques and even myocardial infarction and stroke. This means that sensible levels of supplemental calcium should be used (as part of a multi-nutrient tablet, for example) and not grams of calcium, as is available in some shops.

Vitamin D 

As Vitamin D is only found in a small number of foods (eg oily fish, eggs, liver and special mushrooms),

the vast majority of people, especially over 50, fail to get the recommended intake (RDA) of Vitamin D and therefore supplementation is now recommended by the NHS and many health professionals.It is a ‘must have’ and not just a nicety!

Most Vitamin D is made in your skin from sunlight (UV b rays) not necessarily from your diet. This master vitamin is actually made from dehydro-cholesterol in your skin, interacting with sunlight, which then converts to Vitamin D via biochemical steps in both the liver and then the kidney. The problem is that in the UK, the amount of sunlight is low, especially in Winter months, to generate the enough of this master vitamin. In addition, many adults will be covered, even in summer, and many will be using suncream, which in turn will slow down the synthesis of Vitamin D in your skin.

A further fact that many do not really appreciate, is that the rate at which you make Vitamin D in your skin actually decreases as you age, making the case for Vitamin D supplementation even stronger.

This vitamin works in conjunction with calcium and phosphorus, ensuring that these two key bone minerals are absorbed efficiently from the gut and to where they are needed most.

There is also much evidence from a range of sources that intake of Vitamin D higher than the recommended daily intake (RDA) can be beneficial especially in older adults. There is now proof that such additional supplementation can not only help with bone strength, but also even reduce the incidence of falls too, based on real clinical data generated by scientists!

Vitamin D also has other health benefits such as supporting your immune system, your muscle health and even regular cell division too. It is the true ‘master vitamin’ and there are many scientists who believe that the RDA is still far too low and are advocating increasing this daily dose to at least double the current RDA.

Those at most risk of Vitamin D deficiency are those with darker skin, those who are obese and also older adults in general, all of whom are advised to supplement with Vitamin D, preferably in a well formulated multi-nutrient formulation, in which a range of other healthy micronutrients are available.

Protein

This macro is also needed for optimum bone health. This really is of no surprise, as the majority of bone mass is organic and is mainly comprised of protein. However, low dietary protein intake is unhealthy for bone strength as again, the bone in its entirety is being remodelled continuously meaning that all constituents, including protein, must be supplied on a daily basis. We know that the scientific data from food intake studies across the UK ( managed by Public Health England), that the up to date RDA for protein(around 100g per day) is not being met by the vast majority of older adults, so supplemental protein may be required.

Vitamin K 

Another key nutrient that is often forgotten about is Vitamin K , which also plays a key role in the formation of bone and there is growing evidence that diets rich in Vitamin K could play a role in helping to maintain bone density in people with osteoporosis, which in turn has been shown is some studies to reduce fractures too. It’s sister vitamin, namely Vitamin K2 in particular, plays a key role in calcium metabolism and has been shown in clinical studies to remove calcium from atherosclerotic plaques in the blood vessels and move this calcium back into bones, where it is required, not in the walls of the arteries!

Magnesium, Zinc, Copper and Iron 

Bones are also composed of other minerals besides calcium and phosphorus. Two key minerals that are essential for bone health are manganese and zinc, both of which have been proven scientifically to contribute to bone health and carry approved health claims according to the EU Food Safety Agency. In addition, a recent meta-analysis(where a group of relevant clinical studies pool their data) shows that those patients with osteoporosis have lower levels of these four key minerals than healthy subjects.

B Vitamins 

Most health care professionals are not aware of the potential benefits brought about by B vitamins, as these are mostly associated with energy metabolism and fighting fatigue. However, there is now a wall of evidence, using long term observational research, that shows that vitamins B12, B6 and also Folate are associated with higher bone mineral density and lower fracture rate. These vitamins seem to work by managing levels of a toxic metabolite in the blood called ‘homocysteine’, which builds up in our blood as we age.

High homocysteine levels in blood are associated with poor bone health (and other negative health effects), so by controlling these levels with these three B vitamins, is believed to help protect bone mass.

Vitamin C, Manganese and Copper 

In further scientific studies, Vitamin C has been shown to contribute to the formation of collagen, which is the main constituent of the all-important spongy cartilage layer between bones, protecting the bones from each other, whilst Manganese and Copper are proven scientifically to contribute to the maintenance of tendon and ligament health. As bones are attached to both tendons and ligaments, then the use of these supplements is highly relevant. Again, if you can use a multi-nutrient tablet which included these key nutrients, then this is the preferred route to optimum bone health.

Take Way Messages:

• Around 50% of women and 20% of men will get osteoporosis and they will need to manage this carefully.
• Screening of women in particular, using DEXA, is the gold standard and will give you your risk of acquiring the disease.
• The use of a daily and well formulated supplement, containing a mix of vitamin D (at least 800 IU), Calcium (avoid high dose tablets), Magnesium, Copper, Zinc and Iron would be a useful addition to the diet to ensure adequate intake of these key micronutrients.
• Ensure you have an adequate amount of protein daily, such as from milk, meat, fish and also a well formulated whey containing supplement.